Homoeopathy faces challenges and they are significant. Some come from the outside and some are from our own making. Challenges should not be avoided but embraced. It is only through struggle and pressure that significant change can occur. We, as a profession need to be honest about the challenges confronting us and realize that the inside is often simply the mirror of the outside. We know this to be so from our philosophy and theories of healing.
There are significant differences of opinion about the fundamentals of what actually constitutes homeopathy. What defines it even. We have considerable challenges in relation to homeopathic research. We have significant education problems also.
To my mind in the teaching of homoeopathic medicine worldwide, there is slightly too much emphasis on the teacher, the guru. Teaching is not about teaching, teaching is about learning. From what I’ve seen, a teacher can be inspiring, and that counts for a lot. But in addition, education theory reminds us that teaching and learning is all about exploring ideas together, reminding people what they already know, encouraging them to reflect, as well as analyse and evaluate, critically.
One area of homeopathy practice that lends itself to opinion is case management. While the theory and principles have been explored in the previous volume, what remains unexplored is the application of those ideas and principles in reality. To a great extent they are truly incongruent.
The title of this book could easily be, Contemporary People Management Strategies, Principles and Techniques or, Homeopathic Management of Complex Cases and Difficult People. Examined, explored and described are how we can get better results in our practices for our clients and patients by attempting to apply our philosophy and theory to the contemporary world with our modern patients. Our practices now are all about navigating complex, difficult and uncompliant clients in modern homeopathic case management, a task that asks us to all at once, put our feet firmly on the ground, know the traditions of homeopathy, and acknowledge that there are a significant group of clients that are moving at such a pace and in such a direction that homeopathy is in danger of being left behind.
This book examines ideas of best practice in the often complex management of people and behaviour, and seeks principles as well as practical solutions for working with prescription medications, drug abuse, nutritional challenges and unconventional lifestyles while patients are undergoing homeopathic treatment. In addition, it explores the skills required to practice excellent natural medicine and meet or exceed patient expectations in the 21st century. These skills are not necessarily always exclusively homeopathic therapeutics, they also include management of people, and personal interactive skills.
|Case example. A homeopath (in a distant country) is treating a woman. The presenting symptom is a persistent cough for the past twenty years. Recently under conventional medicine, the cough was suppressed. The patient sought the homeopath’s help as well. The prescription given was Carcinosin 200. The prescription was based on a totality of symptoms taking into account and including her history and full symptom picture. The homeopath received this irate email from the patient’s partner soon after the remedy was given. Hi ***,Prior to our arrival at ***’s office and meeting you, we had just enjoyed three months and one week of no coughing by the light of my life, ***. I understand that you welcomed *** and instructed her that it would take time to completely rid her of that persistent cough that she has endured for the past TWENTY odd years, BUT you are not here listening to it day in and day out getting worse and worse every *** day!!! |
I completely agree (even though you never vocalized it) with you that the flaming idiot here in *** *** is a fraud. Are you? How much longer will *** have to put up with this before we start to see an improvement?
Some straight answers would be appreciated.
How you deal with this real situation (because it is going to happen at some point to every homeopath, or something similar) is pivotal in your success in practice and longevity in this work. If it’s not an example like this one, it will be something similar.
In this instance, after getting over the initial shock of the email, the homeopath called the patient, let her know she had received this email, and had a frank conversation with her. To paraphrase, the homeopath indicated that if the patient wanted to continue with homeopathic treatment, she was going to have to speak to and manage her husband. Two hours later this apology email arrived.
I apologize for being harsh and there is no reason for my being that way to you. Again, please forgive me.
I want to thank you for responding to my curt email. I am very concerned with ***’s health as I’m sure you are aware of and the fact that *** trusts you means that I trust you as well. Yes, I do believe that you can help ***, but I also believe that when you take on a new client/customer that you keep in touch with them more frequently in the beginning to help them through the transition period. It always worked well for me in my sales career and I’m sure that it will work for you as well. If I had waited for my clients to call me back, I would still be working and not retired for the past 12 years.
*** is a procrastinator and after asking numerous questions of what, how long, when etc. I decided to ask you directly.
The fact that *** likes and respects you and also that she won’t be going back to *** *** is a blessing. Keep up with your good work and more communication, and this will be my last letter, other to say THANK YOU!!
This type of situation requires immediate action. Make sure that you are feeling fully grounded before contacting the patient, and able to resist the bait of being pulled into a power struggle. Make your points with kindness, respect, clarity, and firmness. Be prepared for the possible loss of the patient as well. Obviously, it’s not the desired outcome, but is a possibility. Be aware of this potential loss as a trigger for your own issues with rejection (we all have them), and then take action.
2 What Makes a Case Complex?
At the outset I want to create some context and understanding about what makes a case just a typical case and what makes a case a complicated or difficult case. Some suggest that cases are complex because of difficult symptoms. After all, clients present to homeopaths with pathologies and dramas. While this is undoubtedly so, the symptom picture is not the sole focus of this subject. You will see that there is an extra word here – management. This word implies that we are not so much fixing clients and sending them away, rather we are managing them and their corresponding behaviours. Managing them implies a relationship.
At times, where we take a case can contribute to its complexity. Sometimes we are prescribing in hospitals, aeroplanes, tunnels, nursing homes, tents, villages, folk festivals, drug and alcohol clinics, the back of trucks as well as our comfortable offices.
When I have asked students and practicing homeopaths in the past to consider what makes a case complex, they have come up with an interesting array and a list of possibilities,
- Expectations not being met
- ‘psychobabble’ i.e. the patient is verbose but hiding behind it (theorizing about emotions; intellectualizing)
- Being very ‘needy’
- Bad-mouthing you
- Feigning illness
- Manipulation; feeling ‘taken advantage of’
- When the boundaries get blurred
- When the relationship dynamic changes
- One-sided cases / when the content of information is overwhelming
- Obstacles to cure: nutrition; lifestyle; orthodox drugs
- Multi-miasmatic presentation
- Lots of alcohol and drugs
Fundamentally, cases get complicated and clients require management because of one of the following easily identifiable broad categories:
1 the context
2 the relationship
3 the environment
Sometimes it’s the context. The patient just completely freaks you out. Sometimes case complexity is due to the homeopath’s own lack of familiarity with 21st-century modern living. At other times, a case becomes a complex case because of the obstacles to cure, or the maintaining causes. Sometimes the condition is unknown to you. What is scleroderma for example? Sometimes it’s because of the client’s anxiety. Very often, anxiety levels of a patient due to a specific condition creates many difficulties in the homeopathic conversation and the treatment of a patient. There are also issues around sensitivity. Some people are just plain weird. Sometimes it is because someone’s lifestyle is beyond your comprehension. Sometimes it is because a patient doesn’t want to be there and the patient is reluctant to reveal information to you. And the list goes on.
Sometimes a patient is a deeply traumatized. Sometimes we have language difficulties. Some patients have no boundaries, and some patients decide it is really important to latch on too much, or that it’s really important to fall in love with you. Traumatized patients engage and relate differently to people asking questions, or a listener in a clinical setting. There can be language issues or, for whatever reason, there are emotional or energetic sensitivity issues.
Cases can become complex and complicated because of difficult situations, difficult people, because of the relationship between the practitioner and the patient (and other well-intentioned people in the patient’s circle), and interpersonal skills of either the practitioner or the patient. Most of the time, complexity in a case arises due to the relationship between the patient and the practitioner. At the heart of it, a patient becomes difficult when the patient does not fit into our model of working, when the patient’s behaviour is not the behaviour the practitioner is expecting.
All of the situations described previously require more of the practitioner, extra time, extra attention and better skills. And at times, just as we would expect in the corner store, a customer becomes a difficult customer. Over the years I have had multiple run-ins and experiences with difficult clients.
|Case example:Once I was treating a man who was referred by his sister. He walked in and sat down started telling me, in the first breath, about three striking symptoms. The first was his constant feeling of embarrassment, that people were watching him, he had shyness and his feelings of embarrassment were such that they really held him back socially and it was getting in the way. In addition to that, he implied in a roundabout way that he was having some sort of difficulties sexually gaining and maintaining an erection. He wasn’t clear about this symptom because it was so early in the consultation, and as a consequence, I really didn’t push it. He did say that he had recurring numbness in his genitals however. The other thing that he spoke about at the time was his propensity since a small adolescent to steal clothes off strangers’ clotheslines. He was a pretty out-there guy.Since I don’t have an issue treating the eccentric or weird, I gave him a homeopathic remedy. I prescribed him White-tailed spider 30. It was about a year after the proving of White-tailed spider, and in that proving manual, there were a number of striking symptoms, including strong feelings of embarrassment and numbness of the genitals. It seemed like a good idea at the time. When he returned a couple of weeks later, he reported that the numbness was better and the embarrassment was better, but a number of other issues had arisen. He left that second consultation without a remedy because I wanted to do some work on the case and see what else I could come up with. A week later, he came back to pick up his remedy and he asked me immediately what I wanted to give him. ‘The remedy you need is Opium’, I told him. ‘Oh, he said disappointingly I want to take something called Nux vomica, because I’ve been reading about it and I think I need it.’ I asked him what he meant. He pulled out a notebook from his bag. ‘I’ve been learning about this thing called the repertory,’ he said. ‘I went to the public library and I looked up in this big book called a repertory all of my symptoms.’ By this time, he had opened the notebook where he had written every remedy listed in all of the rubrics he had found himself. Included in his list, that went from many pages was, ‘desires fish, aversion to salt, and all these other things.’ I said to him ‘this is all very well but you don’t actually understand yet how to a use the repertory in an appropriate way. For example there are many other things that you’ve told me in the last couple of weeks that are much more important than these symptoms you have chosen.’ He started to get offended and leaned forward on the seat and he started to point and yell. ‘But this is the remedy I want you to give me’, he yelled. ‘But it’s not indicated,’ I said. ‘I don’t care what you think,’ he yelled, ‘just give it to me.’ ‘You are asking me permission to take a remedy that you want to take that I don’t think is indicated? Have I got that right?’ I said. ‘Yes,’ he said still agitated and heated. ‘I really don’t think this is a good idea,’ I said. ‘You’re a person that has a history of stealing women’s clothes from clotheslines and I can tell you right now that the remedy you want take cannot help you on any level.’ By now he was standing over me and I was worried that it was going to get violent before he stormed out of the office and I never saw him again. How did I handle that situation? Well in hindsight, I’d say not very well. I had an opportunity to manage that situation and it went poorly.|
|Case example:One client in particular was always my favourite. I always looked forward to her coming on a Thursday evening, every three or four weeks. She was from Iraq and had been a refugee from the 1970s from what I could work out. She smoked 40 cigarettes a day and looked terrible. She bought her daughter to translate the first time she came for a consultation, and she refused to give me her date of birth. Judging from the age of the daughter, and putting together a few other aspects of the case, I put her about 45. She looks 60, was overweight and had a host of problems. These problems included searing pains that she described pointing at different parts of the abdomen without being able to really explain any further. In addition, there was terrible burning, but she couldn’t really tell me where and neither could the daughter. I did my best and so did she.At one point in the consultation, she asked to go the toilet and I took the opportunity to speak quite freely with the very articulate daughter. Her daughter explained that her mother had been having a bad time of late, she was always in tears, she didn’t like Australia, the husband was never around and worst of all, the daughter was getting married and was moving away from home, and the mother was desperately upset. At this point, the woman walked back into the room and she clearly made a decision while she was out in the lavatory. She leaned forward and touched me on the arm and said, ‘Doctor, (which I am not) I like you, I am never ever going to see my other doctor ever again.’ She pulled out all of her medications, which was about 12 packets of drugs from her bag and she said ‘I not undertake these any more, I see no one, I see nobody, I trust you, I like you [sic].’ I was doing my best to interrupt and calm her down and say, ‘well, hang on just a moment, let’s explore why you have been taking some of these drugs,’ when she interrupted again. ‘I want you to come to my house,’ she said, ‘I want to cook for you. I want to look after you and I want you to meet Hannah, my other daughter.’ It was a hilarious situation. And most importantly, it took some skill on my behalf to encourage her that she should still see her doctor, and to realise the role that homeopathy might have in her life, all the while her daughter was translating. It was a complex situation because of language, because of understanding, because of context, because her expectations and mine were completely different. There was a massive amount of cultural interpretation in there as well.|
What does a typical work-day look like for me? I wake up slowly, having had the most delightful dreams that I am able to recall easily and vividly. I write them down while I am drinking my exquisite tasting morning coffee. The croissant is perfectly made, slightly warm and delicious. There is absolutely no traffic on the roads, and I’m able to get from my house to my office in a medium amount of time, gently listening to some Ravel or Elgar. I walk in the clinic and everything is in place ready for me. I sit down, and my first patient comes in and talks. The patient gives me all the characteristic information I need. I immediately know the remedy, and I have it in my dispensary, I make it up and give it to my smiling client. The prescription is brilliant. My patient is perfectly compliant. The patient knows how to take the remedy. The patient walks out of my office and tells all their friends about the great experience with homeopathy, and what a lovely man the homeopath is.
Of course, here’s what actually happens. By the time I get to the office, late because of traffic, having had a lukewarm flat white made by a surly gen-Y 20-year-old who doesn’t care about anything except getting a new tattoo, and my client is sitting in the waiting room, agitated and full of awkward questions. He has been dragged in by his wife for snoring, which of course he denies is an issue at all. The client spends the first 10 minutes saying that he doesn’t really believe in homeopathy anyway because he read something in the Guardian newspaper. He thinks that Richard Dawkins is a really nice bloke and he tries to get a discount from me at the end of the consultation before he walks away to his BMW, and drives off without making an appointment to follow up.
Friends and Difficulty
Difficulty occurs when our expectations are not met. Over the last decade when I’ve been teaching students all around the world, I have often tried to think of the best analogy when getting students to realize about the realities of practice.
Perhaps the best way to consider it is to take out the word ‘case’ and insert the word ‘friend’. What makes a friend a complicated friend? What is it that happens when a friend stops being a best friend and becomes a difficult friend? When asked this question in class, students often report things like;
- Our relationship changed when she became more demanding
- When he took up too much of my time
- When her expectations changed
- When I had to be with them through that difficult time
- I had no more time to give them
- They just changed
- I grew out of them
- They were hard to manage
Ask a homeopath and they will tell you similar comments about their clients. Ask a bank teller and they will tell you the same thing. But then they get extra training to deal with these customers. So should homeopaths. A difficult client could be one that is hostile, needy, sceptical, manipulative or hypochondriacal.
What follows therefore is an exploration of some clear and repeatable situations that occur in practice. Since these situations often stem from an aspect of the relationship, it is important that we ensure that our end of the therapeutic relationship is attended to. In other words, we must be sure that the difficulty in relating to the client is not because of our own issues, and that we have as much clarity about our own process as is humanly possible. It is important that we objectively assess that we are not getting in the way of clear communication by:
- Articulating clear ground rules for compliance
- Identifying obstacles to cure so patient and practitioner are on the same page with treatment expectations.
In establishing compliance, it is important to remember that patient/practitioner compliance must often be explicitly negotiated, and any discrepancies or any misperceptions about the treatment need to be ironed out and organised at the start of treatment so that the expectations of patient and practitioner are the same.
Why Would a Client Not Be Compliant?
Homeopaths often consider this question, and reflect back on those patients who have moved on, have stopped treatment, or simply not complied with the usual protocols of homeopathy and what was asked of them. Why on earth would a patient not be compliant with the wishes of a practitioner?
Over the years, patients, students and colleagues have provided the following reasons for non compliance:
- They are not ready
- They don’t understand
- They are disorganized
- They don’t actually trust you
- They are sceptical
- They don’t see the relevance of what is required
- Their personality and nature gets in the way
- They have other priorities
- Excuses such as, I forgot, or it’s in my other hand bag, or I went to Melbourne and forgot to take it with me
- Self sabotage
- Deliberate deceit
- Some sort of unconscious wish to not get any better
Patients can be deceitful; want to have fun with you, lie, be compulsive and they may be doing so unconsciously. One of the most common reasons for non-compliance is that expectations of the patient and practitioner were not the same and not articulated well.
At the first consultation, provide as much information as you can about what homeopathy involves, what the treatment involves and what is expected. A really good tool is to put together an information pack that you could hand to or post out to your patients whenever they make an appointment.
While patients should be responsible for themselves and their health, they should be given the relevant information to understand the demands of the treatment, the consultation and the remedy. That is on their side. On the other side, it is the practitioner’s responsibility to recognise if a client’s needs or expectations are not being met, and refer the client to another practitioner appropriately. The termination of treatment when appropriate is an important skill to develop and practitioners should not be afraid of doing this where required.
In homeopathy, there are all these rules and rituals. Take it once a day, two times and then wait, stir with a spoon and then throw the rest away. It is confusing. As a consequence patient/client compliance needs to be negotiated.
Anxiety and Non Compliance
One of the major reasons for non-compliance in my practice is due to anxiety. Typically patients who suffer from panic attacks and anxious patients are very difficult cases to treat. They can have anxiety about the medicine, what it is, what it’s made from, and how to take it. They may have issues of suspicion, paranoia, poisoning etc that further complicate the management of these cases.
|Case ExampleAn Indian gentleman, thick black hair in his ears, his left eye is bigger than his right eye, bags around eyes, presents with anxiety and panic. ‘I had a big fight with the previous homeopath. I wanted to take Silica, the homeopath wanted to give me Nat mur. Seen five homeopaths, all over Sydney, the last one wasn’t supportive enough. I am wiped out by mental activity. I take on too much, my body can’t cope. I don’t have the strength. If I like the homeopath I do very well.In this case, this patient was fine as long as I gave him the remedy that he wanted to take. He also knew a little bit about about the remedy since he had some textbooks about homeopathy. Of course I gave him Silica and over the next few weeks he did remarkably well on it and came back and reported significant improvement. However, he also said that he had an exam coming up and was very anxious that I give him something for it. Since it was almost 20 years ago and I didn’t know better, I gave in to his anxiety, gave him placebo, made him feel as if he was doing something for his anxiety and for the anticipation of the examinations that were coming up and he again did extremely well. These days I don’t give placebo because in Australia it’s illegal (breaches fair trading legislation) and as many would argue, unethical as well. So just exactly what do we do with these clients?|
It doesn’t help the process when, for whatever reason patients are less than liberal with the truth. It’s hard to comprehend but it happens at times.
|Case exampleI remember the case of a woman who came to see me with her mother as support. The mother was in tears, and the presenting symptom was that she wanted to stop smoking dope. She was an interesting woman with quite a story, made more complicated by the fact that until recently her partner had been a drug dealer and had access to easy and plentiful quantities of marijuana. She was also ‘clairvoyant’ and told amazing stories of seeing dead people, and described herself being ‘half dead.’I gave her Stramonium and a month later she reported significant improvement. When she failed to turn up for her next appointment (the third), I called her on her mobile phone but that number was dead. I called the landline number to her work, and was told that no one by that name had ever worked there. The home number didn’t exist. She had given me a fictitious name, fictitious details and who knows what the outcome is, where or how she is these days.|